Basic Information
Provider Information | |||||||||
NPI: | 1205829934 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SRA VENTURES INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WESTCOAST RADIOLOGY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 501 S LINCOLN AVE | ||||||||
Address2: | #15 | ||||||||
City: | CLEARWATER | ||||||||
State: | FL | ||||||||
PostalCode: | 337565901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7274466760 | ||||||||
FaxNumber: | 7274412465 | ||||||||
Practice Location | |||||||||
Address1: | 501 S LINCOLN AVE | ||||||||
Address2: | #15 | ||||||||
City: | CLEARWATER | ||||||||
State: | FL | ||||||||
PostalCode: | 337565945 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7274466760 | ||||||||
FaxNumber: | 7274412465 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2005 | ||||||||
LastUpdateDate: | 04/05/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ABOUD | ||||||||
AuthorizedOfficialFirstName: | ANTHONY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7274466760 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SRA VENTURES INC | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) | 261QR0206X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 261QR0200X | HCC2621 | FL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.